Availability of off-marketplace plans with lower premiums for higher-income families.

OBJECTIVES: Families with incomes above 400% of the federal poverty level were ineligible for marketplace premium tax credits before 2021 and may again be after 2025. Current laws temporarily removed this income cap, but because credits cap out-of-pocket premiums for a reference plan as a share of income, some higher-income families still receive zero tax credits. We quantified (1) premium differences between on- and off-marketplace plans and (2) the association between these premium differences and state decisions to finance cost-sharing reductions (CSRs) for lower-income families. STUDY DESIGN: We created a comprehensive database of on- and off-marketplace plans in each county (including both federal and state-based marketplaces). METHODS: By county and metal level, we compared on- and off-marketplace (1) plan premiums in 2020 and (2) growth rates in the numbers of plans. We contrasted outcomes for states by how insurers were instructed to finance CSRs. RESULTS: In 2020, 89% of the US population lived in counties where some plans were offered exclusively off-marketplace. In these counties, for a 45-year-old choosing among silver plans in 2020 and who did not qualify for premium subsidies, premiums for the lowest-cost off-marketplace plans averaged 11.3% less than premiums for the lowest-cost on-marketplace plans. In contrast, for bronze and gold plans, the lowest-cost off-marketplace plans were, on average, more expensive. Silver plan premiums were 6.1% higher off-marketplace than on-marketplace in states that loaded CSRs on all silver plans, and 13.5% lower in states that loaded CSRs only on on-marketplace silver plans. CONCLUSIONS: Higher-income individuals and families may consider purchasing Affordable Care Act-compliant silver plans off-marketplace and thereby reduce their premiums. State and federal policy makers should consider the impact of their decisions on the choice between on- and off-marketplace plans.

Association of Disability Compensation With Mortality and Hospitalizations Among Vietnam-Era Veterans With Diabetes.

Importance: It remains poorly understood whether income assistance for adults with low income and disability improves health outcomes. Objective: To examine the association between eligibility for disability compensation and mortality and hospitalizations among Vietnam-era veterans with diabetes. Design, Setting, and Participants: Quasiexperimental cohort study of a July 1, 2001, policy that expanded eligibility for disability compensation to veterans with "boots on the ground" (BOG) during the Vietnam era on the basis of a diagnosis of diabetes; veterans who were "not on ground" (NOG) remained ineligible. Participants were Vietnam-era veterans with diabetes in the Veterans Affairs Healthcare System. Difference-in-differences were estimated during early (July 1, 2001-December 31, 2007), middle (January 1, 2008-December 31, 2012), and later (January 1, 2013-December 31, 2018) postpolicy periods. Data analysis was performed from October 1, 2020, to December 1, 2021. Exposures: Interaction between having served with BOG (as recorded in Vietnam-era deployment records) and postpolicy period. Main Outcomes and Measures: Primary outcomes were all-cause mortality and hospitalizations. Results: The study population included 14 247 BOG veterans (mean [SD] age at baseline, 51.2 [3.8] years; 25.7% were Black; 3.3% were Hispanic; 63.6% were White; and 6.9% were of other race) and 56 224 NOG veterans (mean [SD] age, 54.2 [6.3] years; 21.7% were Black; 2.1% were Hispanic; 67.1% were White; and 8.2% were of other race). Compared with NOG veterans, BOG veterans received $8025, $14412, and $17 162 more in annual disability compensation during the early, middle, and later postpolicy periods, respectively. Annual mortality rates were unchanged (prepolicy mortality rates: 3.04% for BOG and 3.56% for NOG veterans), with adjusted difference-in-differences of 0.24 percentage points (95% CI, -0.08 to 0.52), -0.08% (95% CI, -0.40 to 0.24), and -0.08% (95% CI, -0.48 to 0.36), during the early, middle, and later postpolicy periods. Among 3623 BOG veterans and 19 174 NOG veterans with Medicare coverage in 1999, a population whose utilization could be completely observed in our data, BOG veterans experienced reductions of -7.52 hospitalizations per 100 person-years (95% CI, -13.12 to -1.92) during the early, -10.12 (95% CI, -17.28 to -3.00) in the middle, and -15.88 (95% CI, -24.00 to -7.76) in the later periods. These estimates represent relative declines of 10%, 13%, and 21%. Falsification tests of BOG and NOG veterans who were already receiving maximal disability compensation prior to the policy yielded null findings. Conclusions and Relevance: In this cohort study, disability compensation among Vietnam-era veterans with diabetes was not associated with lower mortality but was associated with substantial declines in acute hospitalizations. Veterans' disability compensation payments may have important health benefits.

Incorporating respondent-driven sampling into web-based discrete choice experiments: preferences for COVID-19 mitigation measures.

To slow the spread of COVID-19, most countries implemented stay-at-home orders, social distancing, and other nonpharmaceutical mitigation strategies. To understand individual preferences for mitigation strategies, we piloted a web-based Respondent Driven Sampling (RDS) approach to recruit participants from four universities in three countries to complete a computer-based Discrete Choice Experiment (DCE). Use of these methods, in combination, can serve to increase the external validity of a study by enabling recruitment of populations underrepresented in sampling frames, thus allowing preference results to be more generalizable to targeted subpopulations. A total of 99 students or staff members were invited to complete the survey, of which 72% started the survey (n = 71). Sixty-three participants (89% of starters) completed all tasks in the DCE. A rank-ordered mixed logit model was used to estimate preferences for COVID-19 nonpharmaceutical mitigation strategies. The model estimates indicated that participants preferred mitigation strategies that resulted in lower COVID-19 risk (i.e. sheltering-in-place more days a week), financial compensation from the government, fewer health (mental and physical) problems, and fewer financial problems. The high response rate and survey engagement provide proof of concept that RDS and DCE can be implemented as web-based applications, with the potential for scale up to produce nationally-representative preference estimates.

Verbal Working Memory Error Patterns and Speech-Language Outcomes in Youth With Cochlear Implants.

PURPOSE: Verbal working memory (VWM) delays are commonly found in prelingually deaf youth with cochlear implants (CIs), albeit with considerable interindividual variability. However, little is known about the neurocognitive information-processing mechanisms underlying these delays and how these mechanisms relate to spoken language outcomes. The goal of this study was to use error analysis of the letter-number sequencing (LNS) task to test the hypothesis that VWM delays in CI users are due, in part, to fragile, underspecified phonological representations in short-term memory. METHOD: Fifty-one CI users aged 7-22 years and 53 normal hearing (NH) peers completed a battery of speech, language, and neurocognitive tests. LNS raw scores and error profiles were compared between samples, and a hierarchical regression model was used to test for associations with measures of speech, language, and hearing. RESULTS: Youth with CIs scored lower on the LNS test than NH peers and committed a significantly higher number of errors involving phonological confusions (recalling an incorrect letter/digit in place of a phonologically similar one). More phonological errors were associated with poorer performance on measures of nonword repetition and following spoken directions but not with hearing quality. CONCLUSIONS: Study findings support the hypothesis that poorer VWM in deaf children with CIs is due, in part, to fragile, underspecified phonological representations in short-term/working memory, which underlie spoken language delays. Programs aimed at strengthening phonological representations may improve VWM and spoken language outcomes in CI users.

Remote Assessment of Verbal Memory in Youth With Cochlear Implants During the COVID-19 Pandemic.

Purpose Youth with cochlear implants (CIs) are at risk for delays in verbal short-term memory (STM)/working memory (WM), which adversely affect language, neurocognitive, and behavioral outcomes. Assessment of verbal STM/WM is critical for identifying and addressing these delays, but standard assessment procedures require face-to-face (FTF) administration. The purpose of this study was to determine the feasibility and validity of remote testing methods (teleassessment) of verbal STM/WM in youth with CIs as a method of addressing COVID-19-related restrictions on FTF test administration. Method Tests of verbal STM/WM for nonwords, digit spans, letter-number sequences, sentences, and stories were individually administered by speech-language pathologists over a teleassessment platform to 28 youth (aged 9-22 years) with CIs and 36 same-aged normal-hearing peers. Examiners, parents, and participants completed quality and satisfaction ratings with the teleassessment procedure. Teleassessment scores were compared to results of tests obtained at FTF visits an average of 1.6 years earlier. Results Quality and satisfaction ratings for teleassessment were high and in almost all cases did not differ between the CI and normal-hearing samples. Youth with CIs scored lower than normal-hearing peers on measures of verbal STM/WM, and scores for digit span and letter-number sequencing did not differbetween teleassessment and FTF methods. Correlations across teleassessment and FTF visits were strong for digit span, letter-number sequencing, and sentence memory, but were more modest for nonword repetition. Conclusion With some caveats, teleassessment of verbal STM/WM was feasible and valid for youth with CIs.

The Impact of Residents on Patient Satisfaction.

BACKGROUND: High-quality physician communication is the foundation for achieving high patient satisfaction. Increasing importance is placed on eliciting feedback from patients. However, there have been few studies looking at the impact of resident involvement on patient satisfaction. Our hospital system values the patient's likelihood to recommend the practice as the top marker for patient satisfaction. METHODS: Between May 2016 and December 2016 at University of California, San Diego, all outpatient appointments were randomly mailed Press-Ganey surveys or an eSurvey regarding their experience. The surveys were filtered based on resident participation, and an χ test was performed to assess the impact of residents. An additional aim was to determine the degree to which the impact of resident involvement differed between surgical specialties. Binomial probability was calculated for each specialty using the 'no resident' group as the reference percentage. RESULTS: A total of 73,834 surveys were mailed or sent electronically, and 17,653 surveys were returned (23.9% response rate). Overall, patients expressed high levels of satisfaction with the quality of physician communication. Patients who had residents involved in their care reported a decrease in satisfaction with physician communication and a decrease in the likelihood to recommend the practice (88.7% vs 90.4%, P < 0.001). In the analysis of resident impact by surgical specialty, 9 specialties qualified for analysis. Resident involvement was associated with lower physician communication scores in orthopedic surgery (P = 0.032), otolaryngology (P = 0.015), and vascular surgery (P = 0.01). In all other surgical subspecialties, there was no statistically significant difference between groups. CONCLUSIONS: Overall, patients expressed high levels of satisfaction with the quality of physician communication with and without resident involvement. Resident physician involvement in surgical clinic visits was associated with lower overall patient satisfaction and decreased likelihood of recommending the practice. In addition, we observed that resident involvement was not associated with lower communication scores in most surgical specialties, including Plastic Surgery.

Genome Sequence of Mycobacteriophage Phayonce.

Mycobacteriophage Phayonce is a newly isolated phage recovered from a soil sample in Pittsburgh, PA, using Mycobacterium smegmatis mc(2)155 as a host. Phayonce's genome is 49,203 bp long and contains 77 protein-coding genes, 23 of them having predicted functions. Phayonce shares a strong similarity in nucleotide sequence with phages of cluster P.

Congruity influences memory and judgments of learning during survival processing.

A recent line of research has suggested that memory systems evolved to encode fitness-relevant information more effectively than other types of information-a phenomenon known as the "survival processing effect" (Nairne, Thompson, & Pandeirada Journal of Experimental Psychology: Learning, Memory, and Cognition 33:263-273, 2007). However, the basis for the effect has been debated. In addition, it is unknown whether or not individuals will adjust their judgments of learning (JOLs) to reflect the survival processing effect. In three experiments, participants rated 16 words for their relevance to a survival scenario and another 16 words for their relevance to a bank robbery scenario. In Experiment 1A (with no JOLs), the survival processing effect emerged; in Experiment 1B (with JOLs), no survival processing effect emerged, but JOLs were higher in the survival condition. In both cases, these findings were confounded by higher relevance ratings in the survival condition. In Experiment 2, relevance was manipulated within each list, and the survival processing effect was eliminated. Instead, both recall and JOL magnitude were related to level of congruity between the words and type of processing. Together, these results provide further evidence for the role of congruity in the survival processing effect and JOLs.